Ethnography as a tool to understand cultural determinants of antibiotic prescribing behaviours in different settings

Hi. My name is Esmita Charami. And in this lecture, I’m going to be talking you through the research that we have done using ethnographic methods to try and better understand the cultural determinants of antibiotic prescribing behaviours in different settings and different specialties. The definition of culture that we use in our research is the shared knowledge that people use to interpret experience and generate behaviours as members of a group. It’s about the social norms, values, and assumptions that people identify with as members of the group. And the reason we use this definition is because it is anchored in and derived from concrete observations of behaviour and context. In our case, about clinical decision making, or the clinical setting as the context.

And it also relies on using anthropology and ethnographic approaches, which is direct observation of behaviours, which you’ve been talked about– taught about already in this course. And, hopefully, you’ve paid attention to that. But ethnography describes how a group constructs its environment and what behaviours are discernible amongst its members. And it relies on observations, but also it can be about interviewing individuals through in-depth face-to-face interviews about why and how they behave the way they do. In our research, when we began to do this, we developed a model for the cultural factors around implementing antibiotic stewardship in hospitals. So we’re very interested in the physical environment and how people interact with it. For example, meetings, ward rounds, handover, and teaching and training.

We’re very interested in what tools individuals use to inform their decision making, whether they use diagnostic tools, whether they use policy and guidelines. And we’re also interested in the social environment– how people interact with each other as members of a team, and how that interprets itself, and it’s translating to behaviours. We conducted ethnographic research across medical and surgical specialties in a very busy Hospital in London. And we chose acute medicine and acute surgery because these are the first division in terms of differences in specialties in hospitals. And we wanted to see how we can develop more contextually fit interventions.

In order to be able to do that, we first had to understand whether there were differences between how different specialties diagnose and treat infections, and how much team identity and the culture within teams influences that. And so we spent many, many hours of observation with both teams. And we also interviewed the key stakeholders across these specialties to also get their point of view about how antibiotic decision making occurs. And what we were able to describe is that there are differences between these specialties. In the surgical teams, there is a lot more individualistic decision making being made. And physicians or the surgeons make loose and complex decisions.

And the senior team are often absence from the ward due to the pressure to be in the operating room or in the outpatient clinics. And this leaves a vacuum for decision making about care related to the patient that is not surgical. And infection and antibiotic prescribing is considered not to be surgical by them, by the surgeons who see themselves as interventionists. In the medical specialties, there’s generally a lack of ownership between the emergency room and inpatient teams. And this is partly because of fear of sepsis driving the broad spectrum use of antibiotics in the emergency department, and the reluctance of the teams to take over the care of the patient to counter the decision made in the emergency department.

So, overall, we were able to describe that antibiotic management is peripheral to the role of the surgeons and it isn’t often prioritised, and it can be delegated to other health care professionals. Effective antibiotic management is often frustrated by diffusion of responsibility and a lack of continuity because of how the teams spread and how that leads to communication gaps. But there are ways we can improve this. And one way would be to look at assigning explicit roles and responsibilities to members of the team within a surgical specialty who are then responsible for ensuring patients’ antibiotic prescribing is appropriate, but also to develop better stewardship focused interventions in surgery that takes into consideration the needs of the surgical team.

The surgical team, for example, start their day at 7:30 with a handover of the patients. And that may be an opportunity to look at how even the timing– something as simple as the timing of when the stewardship team are present on the ward, can make a difference in how engagement– how much engagement you have with the surgical teams. We also tried to map– through this ethnographic research, we tried to map the– all these steps in the surgical pathway where there is a risk of transmission of infection. And, by default, there’s also an opportunity for developing better interventions or improve existing processes to prevent the spread of infection, and promote antibiotic stewardship, and appropriate antibiotic prescribing.

And what we found is when we map this process and we looked at the evidence from the literature, the overwhelming majority of the evidence for the literature focuses on prevention of surgical site infection and the appropriateness of antibiotic prescribing for prophylaxis. What happens to the patient in the post-operative period when they’re recovering from an operation or when they’re being looked after by the surgical team is a huge gap in antibiotic prescribing and antibiotic stewardship.

So we went on and we were able– we were very fortunate to be able to work with colleagues in South Africa and India to secure funding through the economic and social science research to conduct more qualitative research to better understand the surgical pathway in relation to antibiotics decision making and infection control. So the ASPIRES study– which is investigating antibiotic use across the surgical pathway and redesigning and evaluating systems– is looking at cardiovascular and gastrointestinal surgical teams in India and South Africa, England, Rwanda, to look at how we can provide better contextually fit interventions.

And the reason why it is so important to understand the context is because across different cultural divides, across different countries and economies, there may be different factors that influence decision making and influence the shape and structure and outcome of stewardship interventions. As an example, this is a photo of the outside of the ICU unit in our hospital in India where one of the interventions for infection control is that all staff and patients must remove their shoes before going into the ICU unit. And this is an infection control measure.

But also it’s an indication of some traffic through the ICU at any time, and the possibility of sharing of skin bacteria between patients, and also just spreading– another way of spreading pathogens in the ICU unit. So, for our study, we, in these different settings, we have spent a lot of time identifying the key teams who are involved across the surgical pathway. And these are just the photos of us engaging with anaesthetist teams, with the surgical teams, and to try and get them engaged with the study, but also to get their acceptance that– for the entire teams to be observed for long periods of time and also to be interviewed. So stakeholder engagement is key when conducting ethnographic research.

And there are many different ways that one can ensure rigour in the data collected. My colleagues from South Africa and India will later on, in a series of presentations, talk a lot more about how we achieved this through reflexivity, through triangulation, by getting many different sources of data, by observing different areas of practise, by conducting documentary analysis. But also respondent validation is important. It’s taking the data back to the participants and seeing what they think about the data.

So, so far, in the research that we are conducting across these studies, across these countries, using ethnographic research, we have been able to map the processes across the pathway in surgery to identify where the gaps are in practise, where the strengths are, and what we can learn from different models of care in these different hospitals. We’ve also been able to map the surgical pathway and look at the patient experience. In this research, we are involving the patients– in each step of the research, including as participants. We’re interviewing patients about their experiences, about their understanding and knowledge, and the level of engagement with them about the care that they received in hospitals.

We have also being able to– this is a work in progress– but we are mapping each step in the process of antibiotic prescribing, and infection prevention and control in the surgical pathway to try and identify who is responsible for each step, and how valuable that is, and how important that is, and then trying to implement interventions, and knowing who to target. And what emerges from this data is that there are many different actors and actions involved in antimicrobial stewardship and infection prevention and control. And to develop sustainable and successful interventions, it’s important to consider this.

So, in conclusion, I hope that we have been able to show you through this very whirlwind overview of the research we do that measurement and implementation is a social process that needs to take into account the context and complexity. One way to do this is that we can look at existing lines of influence and champions, and examples of positive deviance that we can learn from. Culture and context have the power to shape antibiotic prescribing behaviours. And one of the ways to best understand this is to conduct qualitative research to be able to develop series, which can then be tested quantitatively. And understanding the cultural determinants is essential in order for us to be able to develop contextually fit interventions.

Thank you very much for listening.